Provider Demographics
NPI:1376544718
Name:PROTHOTIC LABORATORY INC
Entity Type:Organization
Organization Name:PROTHOTIC LABORATORY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:QUIGG
Authorized Official - Suffix:
Authorized Official - Credentials:BOC ABC
Authorized Official - Phone:631-753-4444
Mailing Address - Street 1:2023 NEW HWY
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-1103
Mailing Address - Country:US
Mailing Address - Phone:631-753-4444
Mailing Address - Fax:631-753-4451
Practice Address - Street 1:2023 NEW HWY
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-1103
Practice Address - Country:US
Practice Address - Phone:631-753-4444
Practice Address - Fax:631-753-4451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
ANC0027-01OtherAMERICHOICE
1000002465OtherAFFINITY HEALTH PLAN
A2559046OtherOXFORD HEALTH PLAN
45797OtherAETNA HMO
57C0391OtherCOMMUNITY PREMIER PLUS
G54141OtherEMPIRE HEALTH CHOICE
040810000002OtherFIDELIS CARE
A32A0031OtherABC HEALTH PLAN
3CO793OtherHEALTH NET (PHS
8450582OtherAETNA NON-HMO
000574766OtherUNITED HEALTHCARE
NY01126865Medicaid
8450582OtherAETNA NON-HMO